- Must use AcariaHlth Sp Rx.
- Prior Authorization: Cystic Fibrosis (CF):
Documented Diagnosis: Yes
Medical Test Required: Yes
Age Requirement: >= 2
Duration: 6 Month(s)
Reauthorization Required: Yes
- Cystic Fibrosis (CF):
Age Requirement: >= 2
Duration: 6 Month(s)
Specialist Required: Yes
Documented Diagnosis: Yes
Medical Test Required: Yes
Specialist Type(s): Pulmonologist
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Documented Mutation in the CFTR Gene: Yes
Documented Homozygous F508del Mutation in the CFTR Gene: Yes
Pseudomonas Aeruginosa Culture Required: No
Baseline FEV1 Value (percent predicted): < 90
FEV1 ImprovementMaintenance for Reauthorization: Yes
Liver Function Test Required: No
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